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Prevalence and Definition Estimated 8 million alcohol dependent individuals in the U.S. 500,000 episodes of alcohol withdrawal require pharmacological intervention Alcohol use disorder (DSM-V) As of September 17, 10/33 patients on 8PCU had a primary/admitting diagnosis of drug or alcohol intoxication/withdrawal (unknown number of patients had it listed as a secondary diagnosis) Estimated 15-20% of hospitalized patients afflicted by alcohol use disorder (Kosten et al., 2003)

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DSM-V Diagnostic Criteria for Alcohol Use Disorder A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: Alcohol is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. Craving, or a strong desire or urge to use alcohol. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. Recurrent alcohol use in situations in which it is physically hazardous. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. Tolerance, as defined by either of the following: – A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. – A markedly diminished effect with continued use of the same amount of alcohol. Withdrawal, as manifested by either of the following: – The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). – Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

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Specify if: In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met). In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met). Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted (cont’d) DSM-V Diagnostic Criteria for Alcohol Use Disorder

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Common, Fatal, Costly Problem Alcohol Use Disorders (AUDs) in the United States: – Adults (ages 18+): Approximately 17 million adults ages 18 and older (7.2 percent of this age group) had an AUD in This includes 11.2 million men (9.9 percent of men in this age group) and 5.7 million women (4.6 percent of women in this age group). 3 – Youth (ages 12–17): In 2012, an estimated 855,000 adolescents ages 12–17 (3.4 percent of this age group) had an AUD. This number includes 444,000 females (3.6 percent) and 411,000 males (3.2 percent). 5 Alcohol-Related Deaths: – Nearly 88,000 7 people (approximately 62,000 men and 26,000 women 8 ) die from alcohol related causes annually, making it the third leading preventable cause of death in the United States. 7 – In 2012, alcohol-impaired-driving fatalities accounted for 10,322 deaths (31 percent of overall driving fatalities). 9

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Economic Burden: – In 2006, alcohol misuse problems cost the United States $223.5 billion. 10 – Almost three-quarters of the total cost of alcohol misuse is related to binge drinking. 10 Global Burden: – In 2012, 3.3 million deaths, or 5.9 percent of all global deaths (7.6 percent for men and 4 percent for women), were attributable to alcohol consumption. 11 – Alcohol contributes to over 200 diseases and injury-related health conditions, most notably alcohol dependence, liver cirrhosis, cancers, and injuries. 12 In 2012, alcohol accounted for 5.1 percent of disability adjusted life years (DALYs) worldwide. 11 – Globally, alcohol misuse is the fifth leading risk factor for premature death and disability; among people between the ages of 15 and 49, it is the first. 13 Family Consequences: – More than 10 percent of U.S. children live with a parent with alcohol problems, according to a 2012 study. 14 Common, Fatal, Costly Problem

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DSM-V Diagnostic Criteria for Alcohol Withdrawal Cessation of (or reduction in) alcohol use that has been heavy and prolonged. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in Criterion A: – Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm). – Increased hand tremor. – Insomnia. – Nausea or vomiting. – Transient visual, tactile, or auditory hallucinations or illusions. – Psychomotor agitation. – Anxiety. – Generalized tonic-clonic seizures.

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The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance. Specify if: With perceptual disturbances: This specifier applies in the rare instance when hallucinations (usually visual or tactile) occur with intact reality testing, or auditory, visual, or tactile illusions occur in the absence of a delirium. DSM-V Diagnostic Criteria for Alcohol Withdrawal

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Who is at risk for DT? A history of sustained drinking A history of previous DT Over age 30 The presence of a concurrent illness The presence of significant alcohol withdrawal in the presence of an elevated alcohol level A longer period since the last drink (ie, patients who present with alcohol withdrawal more than two days after their last drink are more likely to experience DT than those who present within two days)

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Assessment – beyond CIWA Questions to ask: – CAGE questions (Kosten et al, 2003) Can you cut down on your drinking? Are you annoyed when asked to stop drinking? Do you feel guilty about your drinking? Do you need an eye opener drink in the morning when you wake up? – How long have you gone without alcohol in the past six months? – Has anyone ever advised that you cut down on your drinking? – When was the last drink (i.e., the most recent alcohol consumption)? – How much alcohol per day? – How long has the patient been dependent on alcohol? – Has he/she ever experienced withdrawal or delirium tremens before? If so, how many times has this occurred, and did he/she ever have seizures?

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Plan and Goals of Care The patient will remain free from falls during the hospital stay by using bed exit alarm and frequent monitoring by staff. The patient will not elope from the hospital during his/her stay through frequent monitoring, purple gown, security alert. The patient will not aspirate during his/her stay by keeping HOB > 30 degrees, monitoring during PO intake, staff evaluation for safe swallow.

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Interventions IV access Administer medications (as ordered by LIP) Possible sitter/safety coach and/or to be closer to nurses’ station If at risk for elopement, place in special gown (at OSUWMC, it is bright purple), notify security of increased risk, and keep close to nurses’ station, away from elevators. Going off the unit is contraindicated, both due to risk for elopement and medication administration Avoid the use of restraints, especially LBB

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Diabetes: A huge public health problem Diabetes affects 29.1 million people of all ages – Diagnosed: 21 million – Undiagnosed: 8.1 million That’s 9.3% of the U.S. population! About 1.7 million adults were newly diagnosed with diabetes in 2012 in the U.S. An estimated 86 million American adults have pre-diabetes By 2050, 1 in 3 Americans will have diabetes!

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Why individuals with diabetes should be concern Medical expenses for people with diabetes are more than 2 times higher than for people without diabetes. The total annual cost of diabetes is $245 billion (CDC, 2014) – Direct medical: $176 billion – Indirect: $69 billion “In 2003–2006, after adjusting for population age differences, rates of death from all causes were about 1.5 times higher among adults aged 18 years or older with diagnosed diabetes than among adults without diagnosed diabetes” (CDC, 2014). INEQUALITIES – those in lower socioeconomic position and non- whites are more likely to develop T2DM

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Diabetes is risky business for your heart Overall, the risk for death among people with diabetes is about twice that of people without diabetes. Poorly controlled diabetes is the 7th leading cause of death in the United States. Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. The risk for stroke is 2 to 4 times higher among people with diabetes.

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… and for your eyes, kidneys, nerves, mouth, and mental health … Poorly controlled diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults in the United States. Those with diabetes have about twice the risk of gum disease than those without diabetes. People with diabetes are more susceptible to many other illnesses. People with diabetes are twice as likely to have depression.

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True or False? Diabetes is the leading cause of blindness, amputations, and kidney problems.

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Pathophysiology Overview The pancreas produces insulin in response to an increase in blood sugar, which occurs after eating food Insulin functions as the “key” to let the sugar into the cells. Without the insulin, the sugar remains in the blood and cannot be used by the cell for daily functions. For those with Type 1 diabetes, the pancreas is unable to make insulin. For those with Type 2 diabetes, the cells have difficulty using the insulin, which happens when the cells become resistant to the insulin. After a while, the pancreas gets “tired” and produces less insulin. Both result in high blood sugar levels, which leaves the cells starved of sugar.

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Glucose Regulation Glucose = major energy source BG level “regulated by rate of consumption and intestinal absorption of dietary carbohydrate, the rate of utilization of glucose by peripheral tissues and the loss of glucose through the kidney tubule, and the rate of removal or release of glucose by the liver” (Nordlie et al., 1999, p. 380). Liver regulates BG level through the following: – Glycogenesis: uptake of extra glucose, to store as glycogen – Glycogenolysis: release of glucose by turning glycogen into glucose – Gluconeogenesis: release of glucose by harvesting amino acids, waste products, fat byproducts – Ketogenesis: when glycogen and insulin levels are low, the liver breaks down fats into ketones to use as energy for less essential organs, reserving glucose for brain, RBCs, some of the kidneys (REMEMBER THIS FOR LATER!)

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Insulin Discovered in 1922 by Banting and Best (Saltiel, 2000) Anabolic (i.e., storage) hormone Essential for appropriate tissue development, growth, and maintenance of whole-body glucose homeostasis Secreted by the β cells of the pancreatic islets of Langerhans in response to increased circulating levels of glucose and amino acids (after a meal) Regulates glucose homeostasis (i.e., balance) at many sites, reducing hepatic glucose output (via decreased gluconeogenesis and glycogenolysis) Increases the rate of glucose uptake, primarily into striated muscle and adipose tissue Affects lipid metabolism by increasing lipid synthesis in liver and fat cells and enhancing fatty acid release from triglycerides in fat and muscle Acts as the “key” to let glucose into the cells, via an insulin receptor on the outside of the cell (extracellular)

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Risk Factors/Demographics Onset at any age, but most are diagnosed when under age 30 Certain HLA types = 3-5x higher risk of T1DM (Pellico, 2013) Genetic predisposition PLUS environmental factors More than 15,000 children and 15,000 adults— approximately 80 people per day—are diagnosed with T1DM in the U.S. annually (JDRF) 85% of people living with T1DM are adults, and 15% children (JDRF) The prevalence of T1DM in Americans under age 20 rose by 23 percent between 2001 and 2009 (JDRF) The rate of T1DM incidence among children under age 14 is estimated to increase by 3% annually worldwide (JDRF).

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Risk Factors/Demographics Obesity (especially visceral/trunk) – BMI >25 kg/m 2 Poor dietary habits Men slightly more than women Sedentary lifestyle/physical inactivity Older age (>45 y.o.) Family history of diabetes – If either parent suffers from T2DM, a child’s risk of developing the disease is almost 15% If both parents have the condition, the risk of developing it is 75%. History of gestational diabetes or baby over 9lbs (10% of those with GD develop T2DM immediately; 35-60% within years)

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Risk Factors/Demographics Impaired glucose metabolism HDL cholesterol 250mg/dL Insulin resistance and hyperinsulinemia Race/ethnicity – Increased risk for African Americans, Hispanics/Latinos, American Indians (e.g., Pima Indians), some Asians, and Native Hawaiians or other Pacific Islanders – Asian Americans have a 9% higher risk of diabetes. Hispanics have a 12.8% higher risk, and non-Hispanic blacks have a 13.2% higher risk of diabetes than non- Hispanic white adults in the U.S. – In children and adolescents, diagnosed more frequently among American Indians, African Americans, Hispanics/Latinos, Asians, and Pacific Islanders

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Gestational Diabetes Mellitus (GDM) A form of glucose intolerance diagnosed during the second or third trimester of pregnancy. Placental hormones cause hyperglycemia and insulin resistance. In up to 14% of pregnancies (Pellico, 2013, p. 820). Usually glucose tolerance testing at weeks, but do earlier if at increased risk. The risk factors for GDM are similar to those for T2DM. Within 1 year after pregnancy, 5% -10% of women with GDM continue to have high BG levels and are diagnosed as having diabetes, usually T2DM % of women with GDM develop T2DM in years. At risk for recurrent GDM with future pregnancies. Treatment: diet, exercise, insulin BG goals: – < 95mg/dL pre-prandial – < mg/dL 1 hour post-prandial – < 120mg/dL 2 hours post-prandial

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Monogenic Diabetes Two forms: Maturity Onset Diabetes of the Young (MODY) and Neonatal Diabetes Mellitus 1-5% of U.S. diabetics have monogenic diabetes, usually MODY Due to mutations in a single gene – 20 genes have been implicated in the development of monogenic diabetes May happen spontaneously BUT has strong hereditary component Management depends on severity of disease Genetic testing of family members necessary

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Maturity Onset Diabetes of the Young (MODY) More common than Neonatal Diabetes Often misdiagnosed as T1DM if found in adolescence or T2DM if later in life Presentation depends on severity; hyperglycemia may be discovered on routine lab work Each child has a 50% chance of inheriting the MODY gene Most commonly caused by mutations in the HNF1A gene or the GCK gene

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Neonatal Diabetes Mellitus – First 6 months of life – Symptoms similar to that of T1DM – Most commonly caused by mutations in the KCNJ11, ABCC8 o r INS genes – Management same as T1DM (need to replace insulin)

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Who gets insulin? (Dungan, 2014) All T1DM Depending on severity, GDM (pregnancy) Eventually, most T2DM – At the time of diagnosis, approximately 50% of beta cell function is lost – Only a matter of time (average about 10 years) before require insulin HbA1c > 8% on two oral agents Unable to take oral agents HbA1c > 10% Symptomatic Other – Hospitalization – Corticosteroid administration – Infection – Cost

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Medication calculation Carbohydrate count – 5 grams of CHO to 1 unit of insulin for tightest control – Can also be 10, 15, or 20 grams CHO: 1 unit Sliding scale insulin (SSI) for BG – Often 1 unit for every 50 mg/dL over 150 mg/dL – Different for every person

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Teaching: SMBG T2DM who are not on insulin  2-3 times per week, including a 2-hour post-prandial, also during medication changes or suspected hyper- or hypoglycemia If on insulin  before meals and at bedtime, suspected hyper- or hypoglycemia Continuous Glucose Monitoring (CGM) Urine Glucose Testing: renal threshold for glucose is mg/dL (affected by age and renal function) Keep a logbook/record – There’s an (well, more than one!) app for that.

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Complications requiring hospitalization: Hyperglycemic Hyperosmolar (non-ketotic acidosis) Syndrome How is it different than DKA?  NO KETOSIS OR ACIDOSIS (insulin is still present) Mortality rate 10-40% Hyperosmolality (> 340mOsm/L) and hyperglycemia (> 600mg/dL) with minimal or no ketosis Older, y.o., with or without T2DM Precipitating events: infection, acute or chronic illness, procedures such as dialysis or surgery, medications